Long-term follow-up of a randomized controlled trial comparing systemic family therapy (FT-S) added to treatment as usual (TAU) with TAU alone in adolescents with anorexia nervosa.

BACKGROUND: Randomized controlled trials showed the efficacy of family therapy for anorexia nervosa during adolescence, but studies examining its long-term beneficial effect are still needed. This article presents the results of a 54-month post-randomization follow-up of a previously reported randomized controlled trial that compared two post-hospitalization outpatient treatment programs: Treatment As Usual alone versus Systemic Family Therapy added to Treatment As Usual. METHODS: A consecutive series of 60 female adolescents with anorexia nervosa (DSM-IV) were randomized (30 per group). During the first 18 months, in the Treatment As Usual group, subjects received a multidisciplinary treatment. In the other group, Systemic Family Therapy sessions targeting intra-familial dynamics were added to Treatment As Usual. At 54 months, the primary outcome was defined using the Morgan and Russell global Outcome Categories (Good or Intermediate versus Poor). Secondary outcomes were the Global Outcome Assessment Schedule score, body mass index, amenorrhea, number of hospitalizations, eating disorder symptoms, psychopathological features, and family functioning. Analyses were carried out using an Intention-To-Treat with the Last Observation Carried Forward procedure. Data of 59/60 subjects were available. RESULTS: At 54 months, significant effects in favor of adding Systemic Family Therapy to Treatment As Usual were shown for the Global Outcome Categories (60% of Good/Intermediate versus 31% in the control group, p = .026), mean body mass index (p = .048), resumption of menses (70.0% vs. 40% p = .020), and mental state score (p = .010). Family cohesion scores were lower in the Systemic Family Therapy group (p = .040). CONCLUSIONS: Adding Systemic Family Therapy focusing on intra-familial dynamics to a multidimensional outpatient treatment program appeared to lead to a better long-term outcome in young women who suffered from severe anorexia nervosa during adolescence.

The ACAMTO study-impact of add-on osteopathic treatment on adolescent patients with anorexia nervosa: study protocol for a randomized controlled trial.

BACKGROUND: Anorexia nervosa (AN) mainly affects women (sex ratio 1/10) and most often starts during adolescence. The prognosis of AN remains poor (10% of deaths and high risk of chronicity). Body dissatisfaction, disturbances in recognition and identification of body sensations are some of the key symptoms of AN. However, there is a contrast between this consensual observation of body image disorders in AN, and the relative deficit of specifically targeted body treatments. Our proposal for a body approach specifically dedicated to AN is based on the understanding that posture, breathing, muscle tension and body perception are closely linked to our psychological and emotional state and are therefore disturbed in patients with AN. The purpose of this monocentric randomized controlled trial is to evaluate if a targeted osteopathic protocol treatment for AN in addition to treatment as usual (TAU) is significantly more effective than TAU alone. METHODS: In total, 72 patients meeting the inclusion criteria will be randomly assigned to one of the two treatment groups: one receiving the specific osteopathic treatment targeted for AN in addition to the TAU (group A) and the other one, receiving TAU only (group B). The patients in group A will receive 5 30-min osteopathic treatment sessions. Soft specific palpatory techniques on the diaphragm, digestive system and cervical region will be performed. The TAU is defined by the multidisciplinary approach recommended by the French health high authority. The primary outcome is the evaluation of interoceptive sensibility and secondary outcomes include clinical and psychopathology-related symptoms with assessment of somatic dysfunctions' evolution. A qualitative study will also be carried out, applying the Interpretative Phenomenological Analysis method. Patients will be included for a maximum of 14 weeks between the inclusion time and the last evaluation. DISCUSSION: If the results of the study are positive (statistically significant efficacy of this osteopathic treatment protocol), the study will provide arguments in favor of osteopathic sessions as a possible non-invasive additional treatment option in the multidisciplinary care approach for patients with AN. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04666415 , Release Date: December 11, 2020; N° ID-RCB: 2019-A02613-54.

Decreased Immune Response in Alexithymic Women: A One-Year Longitudinal Study.

Although previous cross-sectional studies suggested significantly dysregulated immune response in alexithymia, there is a lack of longitudinal studies. We sought to determine the reliability of the reported relationship between alexithymia and decreased immune response in a longitudinal study. Thirty-eight healthy women who had participated in a cross-sectional study were recontacted 1-year later. Of this sample, 26 were finally included: 13 females who had been found to be alexithymic, and 13 females who were classified as non-alexithymic under the 20-item Toronto Alexithymia Scale during the first phase of the study. A year later, they were still healthy women without any psychiatric disorders, their ages now ranging from 19 to 28 years old. Lymphocyte subset counts (CD4, CD8), in vitro production of interleukin 1ß (IL-1ß), IL-2, IL-4, and IL-10 by phytohemagglutinin stimulated peripheral blood lymphocytes, as well as serum cortisol levels, were compared between women with and without alexithymia. One-year later, alexithymic women still had significantly lowered in vitro production of IL-2 and IL-4, with lowered IL-2/IL-10 ratio and a reduced percentage of CD4. This is the first ever published study assessing cytokine production during a follow-up of alexithymics. Although our results should be interpreted with caution due the small sample size, they suggest a sustained reduction in both major type 1 and type 2 cytokines while the former seems to be more affected. The potential long-term health impact, if any, is still to be determined.

A key for perinatal depression early diagnosis: The body dissatisfaction.

OBJECTIVE: To test if the evaluation of body dissatisfaction by images could be an interesting tool to detect perinatal depression early in pregnancy, questioning patients about their body image instead of their depressive symptoms. METHODS: A sample of 457 women was recruited in a longitudinal study. Three evaluations were performed at the 4th and 8th months of pregnancy and during post-partum. During these evaluations, sociodemographic data were collected and psychiatric scales were completed, including Edinburgh Postnatal Depression Scale (EPDS), Eating Disorder Examination-Questionnaire (EDE-Q), Pictorial Body Image Scale (PBIS) and Body Shape Questionnaire (BSQ). RESULTS: 33% of the women who were unsatisfied with their body image suffered from perinatal depression vs. 11.3% of the women who were not (p < 0.0001). The risk of perinatal depression was 4 times higher in women dissatisfied with their body image (p < 0.001) if unintended pregnancy and age are taken into account and is 3 times significantly higher in women with higher levels of eating disorders symptoms (p < 0.001) if unintended pregnancy and age are taken into account. Our sample was a privileged population, as often in the literature. CONCLUSION: The administration of a simple scale (PBIS) during an early visit during pregnancy allows detecting perinatal depression. This should prevent the stigmatization of women during pregnancy and reduce the risk of not diagnosing depression during pregnancy and post-partum.

Predictive factors for outcome in adolescents with anorexia nervosa: To what extent does parental Expressed Emotion play a role?

In studies on family therapy in Anorexia Nervosa, family relationships, as assessed by Expressed Emotion, have been associated with outcome. Our aim was to explore the contribution of Expressed Emotion as a predictor of 18-month outcome, above and beyond the usual predictive factors. Sixty adolescent girls suffering from Anorexia Nervosa and their parents were assessed at baseline and 18 months later. Levels of Expressed Emotion were evaluated in both parents with the Five-Minute Speech Sample. After controlling for treatment group and initial clinical status, high maternal Emotional Over-Involvement at baseline was significantly associated with better clinical state. More precisely, high maternal Emotional Over-Involvement was associated with higher nutritional status, lower eating disorder severity and fewer re-hospitalizations 18 months later. No associations were found with paternal levels of Expressed Emotion. Therefore, our study confirmed the importance of taking into account both maternal and paternal Expressed Emotion. Our results also underlined that high maternal Emotional Over-Involvement plays a positive role in the outcome of Anorexia Nervosa and needs to be explored further.

Impact of somatic severity on long-term mortality in anorexia nervosa.

PURPOSE: Anorexia nervosa (AN) is a severe pathology on account of the high levels of associated morbidity and mortality. This study aimed to assess whether time in somatic intensive care unit, justified by a patient's somatic condition in the course of hospital care, has any relationship with patient outcome in terms of mortality in the long term. METHODS: 195 patients were hospitalised for AN between April 1996 and May 2002, 97 were re-assessed 9 years later on average. RESULTS: Out of 195 patients hospitalised for AN between April 1996 and May 2002, 29 had required transfer to intensive care. Mortality at 9 years was 20 times higher in the group having been transferred to intensive care, irrespective of the duration of follow-up. CONCLUSION: The clinical seriousness of the somatic condition during hospitalisation for AN is a risk factor for excess mortality in the medium term.

Expressed emotion in anorexia nervosa: what is inside the "black box"?

OBJECTIVE: Expressed Emotion has been called a "black box", since little is known about contributing factors. The aim of this study was to examine which parental and which patient/illness-related characteristics contribute to maternal and paternal Expressed Emotion levels. METHOD: Sixty adolescent girls with Anorexia Nervosa (AN) and their parents completed instruments that evaluate characteristics of the adolescent's illness and patient/parental psychological characteristics (depression; anxiety; obsession-compulsion; social anxiety and alexithymia). The following illness-related characteristics were recorded: age at AN onset, duration of illness, AN subtype (restrictive AN-R vs. purging type AN-B), current Body Mass Index (BMI) (in kg/m(2)), minimum lifetime BMI and number of previous hospitalizations, the Global Outcome Assessment Scale total score. Levels of Expressed Emotion were assessed for the two parents using the Five-Minute Speech Sample. RESULTS: Less than 30% of the parents in our sample expressed high levels of Critical EE and Emotional Over-Involvement. Our main findings indicate that maternal Criticism (Critical EE levels, Critical Comments, Dissatisfaction) and the sub-dimensions of maternal Emotional Over-Involvement (EOI EE) (Statement of loving Attitudes and Excessive Details about the past) were related both to the severity of the daughters' clinical state and to maternal psychological functioning. Only paternal levels of anxiety explained paternal Dissatisfaction, EOI EE and Statement of loving Attitudes. DISCUSSION: Parental psychological functioning and the severity of the daughters' clinical state have an impact on the family relationships. These elements should be targeted by individual treatment for parents where necessary, and by psycho-educational sessions about Anorexia Nervosa for parents generally.

Drop-out from adolescent and young adult inpatient treatment for anorexia nervosa.

We examined factors predictive of dropout from inpatient treatment for anorexia nervosa (AN) among adolescents in a prospective study of 359 consecutive hospitalizations for AN (DSM-IV). Patients were assessed at admission (clinical, socio-demographic, and psychological data). Multivariate analyses were performed. Drop-out (i.e. leaving hospital before the target weight is achieved) occurred in 24% (n=86) of hospitalizations; in 42.3% (n=30) of the cases, dropout was initiated by the treatment team and in 58.6% (n=41) by the patients and/or their parents. 18.6% (16/86) occurred during the first half of the inpatient program. Frequency of drop-out was significantly higher when the patient was living with only one parent, had been hospitalized previously, had a lower BMI at admission and was over 18 at admission. These elements should draw the attention of the clinician, so that he/she can prepare hospitalization with patients presenting lower admission BMI, particularly by motivational interventions for a better therapeutic alliance, and by the deployment of intensive accompaniment of single parents. Further studies aiming to replicate these results, and including the evaluation of other clinical dimensions such as impulsivity and other personality traits, are needed to elucidate this important topic.

Bonding and expressed emotion: two interlinked concepts?

BACKGROUND: Bonding and expressed emotion (EE) are two concepts modeling family relationships. Two studies, with contradictory results, have explored whether these concepts and their corresponding instruments [the Parental Bonding Instrument (PBI) and the Camberwell Family Interview] do indeed measure the same aspects of family relationships. Our first objective was to compare the adolescents' perceptions of family relationships using the PBI, and the parental viewpoint using the Five-Minute Speech Sample (FMSS-EE). Secondly, we compared the PBI scores and EE levels of the parents. SAMPLING AND METHODS: Sixty adolescent girls with anorexia nervosa completed the PBI. The FMSS and a modified version of the PBI were administered to parents separately. RESULTS: No significant link was identified between adolescent PBI scores and parental EE levels. However, a link between maternal 'modified' PBI scores and maternal EE was observed: when mothers registered a high Final EE, they were more likely to deny their daughter's psychological autonomy compared to mothers with lower EE. CONCLUSIONS: Our empirical results do not support the hypothesis of an overlap between the two concepts. Indeed bonding and EE measure the same object, i.e. the quality of family relationships, but time scales differ and so do the perspectives (patient vs. parental viewpoint).

Decreased sensitivity to facial emotions in adolescents with Borderline Personality Disorder.

Whereas severe relationship dysfunction in BPD is well described in adolescence, little is known about the way these patients process facial expressions of emotion. Because few data are available regarding this issue, the present study compared the sensitivity to morphed facial emotional expressions of 22 BPD female adolescents versus 22 matched controls. Participants had to identify as rapidly as possible the various emotions displayed progressively and continuously on faces. Results indicate that adolescents with BPD are less sensitive to facial expressions of anger and happiness, i.e. they require more intense facial expressions than control participants to correctly identify these two emotions. However, they did not exhibit any deficit in recognizing fully expressed emotions. These results suggest that sensitivity to facial emotions is impaired in adolescents with BPD. Theoretical and clinical implications are discussed.

A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents.

UNLABELLED: Research on treatments in anorexia nervosa (AN) is scarce. Although most of the therapeutic programs used in 'real world practice' in AN treatment resort to multidisciplinary approaches, they have rarely been evaluated. OBJECTIVE: To compare two multidimensional post-hospitalization outpatients treatment programs for adolescents with severe AN: Treatment as Usual (TAU) versus this treatment plus family therapy (TAU+FT). METHOD: Sixty female AN adolescents, aged 13 to 19 years, were included in a randomized parallel controlled trial conducted from 1999 to 2002 for the recruitment, and until 2004 for the 18 months follow-up. Allocation to one of the two treatment groups (30 in each arm) was randomised. The TAU program included sessions for the patient alone as well as sessions with a psychiatrist for the patient and her parents. The TAU+FT program was identical to the usual one but also included family therapy sessions targeting intra-familial dynamics, but not eating disorder symptoms. The main Outcome Measure was the Morgan and Russell outcome category (Good or Intermediate versus Poor outcome). Secondary outcome indicators included AN symptoms or their consequences (eating symptoms, body mass index, amenorrhea, number of hospitalizations in the course of follow-up, social adjustment). The evaluators, but not participants, were blind to randomization. RESULTS: At 18 months follow-up, we found a significant group effect for the Morgan and Russell outcome category in favor of the program with family therapy (Intention-to-treat: TAU+FT :12/30 (40%); TAU : 5/29 (17.2%) p = 0.05; Per Protocol analysis: respectively 12/26 (46.2%); 4/27 (14.8%), p = 0.01). Similar group effects were observed in terms of achievement of a healthy weight (i.e., BMI≥10(th) percentile) and menstrual status. CONCLUSIONS: Adding family therapy sessions, focusing on intra-familial dynamics rather than eating symptomatology, to a multidimensional program improves treatment effectiveness in girls with severe AN. TRIAL REGISTRATION: Controlled-trials.com ISRCTN71142875.

Decreased immune response in alexithymic women: a cross-sectional study.

It has been reported in a few studies that alexithymia is associated with impaired immune response but results are still contradictory. The present study investigates whether alexithymia is associated with lower cell-mediated (Th-1) immune response. Fifty-one healthy 18-27-year-old women were selected from healthy subjects on the basis of high or low cut-off scores on the 20-item Toronto Alexithymia Scale (TAS-20). They were evaluated using standardized psychiatric rating scales notably the Hospital Anxiety Depressive Scale (HAD) and the Mini Neuropsychiatric Interview (MINI). None of the subjects were suffering from psychiatric disorders. Twenty-seven were classified as alexithymics and 24 as non-alexithymics according to the TAS-20. Blood was drawn for lymphocyte subset counts (CD4, CD8), in vitro production of interleukin 1 (IL-1beta), IL-2, IL-4, and IL-10 by phytohaemagglutinin stimulated peripheral lymphocytes, and cortisol. Women with alexithymia exhibited decreased interleukin 1beta, IL-2 and IL-4 production with reduced ratios of Th1/Th2 (IL-2/IL-10) and of CD4/CD8, as well as reduced CD4 percentages. IL-2 and IL-4 production remained significantly diminished in the alexithymic group, even after adjusting for between-group differences in anxiety and depression levels on the HAD. This study further demonstrates that alexithymic women have altered immune function, with a predominance of depressed cell-mediated immunity and a skewed Th1/Th2 ratio towards Th2 response.

Predictive factors of length of inpatient treatment in anorexia nervosa.

OBJECTIVE: To identify clinical variables influencing the length of stay (LOS) of inpatient treatment for anorexia nervosa (AN). METHOD: We analyzed structured clinical charts of 300 consecutive hospitalizations for AN in a specialized eating disorder unit. The sample included patients from 12 to 22 years old. Factors related to the patient and events occurring during the stay were investigated as possible predictors of LOS. RESULTS: Mean LOS was 135 days. The best model of linear regression revealed that the following factors were significantly related to LOS: duration of AN at admission, use of tube feeding during the stay, accomplishment of the therapeutic weight contract and presence of a comorbid disorder. CONCLUSIONS: The identification of factors influencing duration of stay, both at the outset and during the hospitalization, could help clinicians to optimize and individualize treatments, as well as increase patient and family compliance.

Does the frequency of anxiety and depressive disorders differ between diagnostic subtypes of anorexia nervosa and bulimia?

OBJECTIVE: The objective of the present work is to determine whether the prevalence of depressive and anxiety disorders varies in subgroups of eating disorders (ED) according to age, ED duration, mode of care provision, and body mass index (BMI). METHOD: Using the Mini International Neuropsychiatric Interview (MINI), the frequency of anxiety and depressive disorders was evaluated in 271 ED participants. Their prevalence was compared in subgroups of anorexics (AN-R and AN-BN) and bulimics (BN), both before and after controlling for potential confounding variables. RESULTS: Current or lifetime comorbidity of anxiety and depressive disorders did not differ between AN-R and AN-BN groups. Social phobia, panic disorders, and obsessive-compulsive disorder (OCD) were significantly more frequent in AN-BN and AN-R groups. Panic disorder was more frequent in the BN group. CONCLUSION: Several confounding factors, in particular those identified in the present study, may explain previous conflicting results on the frequency of anxiety and depressive disorders in ED. Nevertheless, the study confirmed that OCD is more frequent in AN, even after controlling for confounding factors.

Expressed emotion and anorexia nervosa: the validation of the Five-Minute Speech Sample in reference to the Camberwell Family Interview.

OBJECTIVE: The goal of the current study was to test whether the Five-Minute Speech Sample (FMSS) assessments of expressed emotion (EE) in families with a daughter with anorexia nervosa (AN) are valid in comparison to the Camberwell Family Interview (CFI). METHOD: The sample included parents of hospitalized patients with AN. Assessments were conducted at the time of patients' discharge from the hospital. The participants (n = 40) were assessed individually with the FMSS and then the CFI. FMSS-EE ratings were classified as high or low for Emotional Overinvolvement (EOI), Critical EE, and Final EE (overall rating). For the CFI, average EE scores were computed on the same subscales. RESULTS: Comparisons of FMSS subgroups on the CFI mean scores revealed that parents rated high EE on the FMSS subscales (EOI and Final EE) had significantly greater mean scores on the CFI than parents rated low EE on the FMSS (EOI: p = .02; Final EE: p = .04). Furthermore, FMSS-EE ratings were positively correlated to CFI-EE ratings for EOI EE (r = .38, p = .01), Critical EE (r = .31, p = .05), and Final EE (r = .29, p = .07). CONCLUSION: The FMSS can reliably measure EE in reference to the CFI in terms of Final EE and EOI EE. For the Critical EE subgroup, further investigation is needed with a bigger sample size.

Is major depressive episode related to anxiety disorders in anorexics and bulimics?

OBJECTIVE: To determine whether the presence of anxiety disorders is related to depressive comorbidity in subjects with eating disorders (ED), while taking into account certain variables that may be related to depression (subjects' age, ED duration, prior incidents of anorexia nervosa in bulimic subjects, inpatient or outpatient status, nutritional state [as measured by body mass index]). METHOD: We evaluated the frequency of depressive disorders in 271 subjects presenting with a diagnosis of either anorexia nervosa or bulimia, using the Mini International Neuropsychiatric Interview, DSM-IV version. RESULTS: A multivariate analysis reveals that anxiety disorders do not all have the same influence in terms of risk of onset of major depressive episode in anorexics and bulimics when adjusted on variables related to depression. CONCLUSION: Depression in subjects with ED can be explained in part by comorbidity with obsessive-compulsive disorder, generalized anxiety, social phobia, and panic disorder.

Testing the Working Alliance Inventory (WAI) in a French primary care setting: predictive value and factor structure.

BACKGROUND: Working alliance has shown a predictive value of the outcome in different therapeutic settings but was not yet studied in a non-medical setting. METHODS: The predictive value and the factor structure of the Working Alliance Inventory (WAI) [36-item client version; as reported by Horvath and Greenberg (J Couns Psychol 36:223-233, 1989)] were studied in a French primary care setting on a sample of 130 adults accessing social services. RESULTS: The WAI total score completed after the first meeting was positively predictive of quality of the working alliance 4 months later. An exploratory factor analysis produced two orthogonal factors which explained 45.12% of the total variance: a first factor (23 items) labelled 'positive expectations about the usefulness of help' and a second factor (13 items) labelled 'absence of suspicion about the effects of help'. CONCLUSIONS: The WAI is shown to be applicable to primary care social work settings to measure the working alliance phenomenon and predict disruption of practitioner-client relationship.

Role of gender and hormone-related events on IgE, atopy, and eosinophils in the Epidemiological Study on the Genetics and Environment of Asthma, bronchial hyperresponsiveness and atopy.

BACKGROUND: The pattern of asthma over the lifespan is different in male and female patients, but etiologic differences according to gender are only partially understood. In women, information regarding factors explaining perimenstrual asthma and the role of hormone-related aspects on asthma-related phenotypes is scanty. OBJECTIVE: To assess the relationships of eosinophils, IgE, and atopy with (1) asthma according to gender and age of onset and (2) hormone-related events. METHODS: Using data from the Epidemiological study on the Genetics and Environment of Asthma, Bronchial Hyperresponsiveness and Atopy, adults and children with asthma recruited in chest clinics (n=313) and first-degree relatives of patients with asthma (n=214) were compared with nonasthmatic controls (n=334) and first-degree relatives without asthma (n=595). RESULTS: Among asthmatic women, eosinophilia was significantly associated with perimenstrual asthma independently from age, smoking, and asthma severity (eosinophils/mm(3) 330 vs 194; P=.01). In nonasthmatic women, IgE level was significantly decreased (by half) and atopy decreased with menopause, and IgE increased with oral contraceptive use, independently from age and smoking. Considering both genders, the increase of eosinophil counts with asthma was significantly greater in women with childhood-onset asthma than in women with adulthood-onset or in men in general. No interaction between gender and asthma was observed for eosinophils in children and for IgE level and atopy in children and adults. CONCLUSION: Results suggest a role of hormone-related events on asthma-related traits and support the hypothesis of the role of eosinophils in the persistence and severity of asthma.

Correlation between serum levels of interleukin-4 and alexithymia scores in healthy female subjects: preliminary findings.

OBJECTIVE: Some studies suggest that inaccuracy in recognizing and describing emotional states, combined with a highly descriptive mode of expression, as in alexithymia, may influence the immune response. We therefore investigated in healthy women the relationship between alexithymia and circulating levels of IL-1, IL-2 and IL-4. METHOD: Seventeen mentally and physically healthy women aged between 20 and 25 years completed psychological questionnaires to assess alexithymia (Toronto Alexithymia Scale: TAS) and depressed mood (Hospital Anxiety and Depression Scale: HAD). Serum concentrations of IL-1, IL-2 and IL-4 were measured by ELISA. RESULTS: We found a significant positive correlation between serum levels of IL-4 and TAS score (r = 0.55; p = 0.021) and between factor 1 of the TAS (difficulty in identifying feelings) and IL-4 (r = 0.57; p = 0.017) while serum IL-1 and IL-2 were not detected in ten and six patients, respectively. Although there was a significant correlation between age and IL-4 levels, a linear regression with BMI, age, depressed mood and TAS as independent variables showed that only alexithymia could predict significantly increased levels of IL-4. CONCLUSION: Alexithymia and difficulty in identifying feelings could be associated with increased levels of IL-4 which may result in chronic impairment of pro/anti-inflammatory cytokine balance with psychological and somatic consequences. Nevertheless, these intriguing findings would deserve replication and extension in a larger sample of subjects.